Abstract

Pain is a challenging area to understand for any healthcare professional, and quality training on the subject is required if nurses are to provide effective pain management and person-centred care. Based on the curriculum developed by the International Association for the Study of Pain, this book offers an essential guide to managing pain. It begins with an examination of the biology of pain, and then goes on to consider pain management across the lifecourse, looking at key topics including acute pain, cancer pain and pharmacology. Case scenarios are included throughout the book to help readers apply the knowledge they have learned to their own practice.It will be valuable reading for undergraduate nurses, and essential for those taking continuing professional development and postgraduate courses in pain ...

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, this publication may be reproduced, stored or transmitted in any form, or by any means, only with the prior permission in writing of the publishers, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.

Library of Congress Control Number: 2014940396

British Library Cataloguing in Publication data

A catalogue record for this book is available from the British Library

ISBN 978-1-4462-8199-4

ISBN 978-1-4462-8200-7 (pbk)

Editor: Alex Clabburn

Associate editor: Emma Milman

Production editor: Katie Forsythe

Proofreader: David Hensley

Indexer: David Rudeforth

Marketing manager: Camille Richmond

Cover design: Naomi Robinson

Typeset by: C&M Digitals (P) Ltd, Chennai, India

Printed in Great Britain by Henry Ling Limited, at the Dorset Press, Dorchester, DT1 1HD

Acknowledgements

[Page v]

This book is dedicated to the memory of my husband Tom, brave endurer of rheumatic heart disease, proud father and loving grandfather

About the Author

[Page x]

Shelagh Wright trained as a State Registered Nurse at St George's Hospital, London (1970), and as a Registered Midwife at the Rotunda Hospital, Dublin (1973). She studied Single Honours Psychology, Trinity College Dublin (1988), undertook a PhD by research (Psycho-oncology) (NUI-Galway, 1999), and has an MA in Healthcare Management (IPA/UCD, 2004) and a Postgraduate Diploma in Statistics (TCD, 2010). Shelagh was Senior Health Promotion Officer for Older Persons (2002–2007), Health Services Executive, Dublin. More recently, Shelagh was instigator, coordinator and Programme Chair for the Dublin City University accredited MSc in Psycho-oncology and Co-Principal Investigator of a postdoctoral study ‘Meaningful methods of identifying psychological distress in patients with advanced cancer’ (Irish Cancer Society), which sought to validate the (NCCN) Distress Thermometer in an Irish context. She is a Registered Psychologist (Psychological Society of Ireland) and PRINCE2 Practitioner (APMG) and is recipient of several awards. An author of non-peer- and peer-reviewed papers, Shelagh has many years' experience teaching undergraduate and postgraduate students as well as substantial experience delivering lectures with video and digital technology. She has a particular interest in Autogenic Training, having completed certificate training under the mentorship of Dorothy Crowther, FRCN Chief Executive Officer, Centre for Autogenic Training, Wirral Holistic Care Services, UK.

Preface

[Page xi]

I am delighted to endorse Pain Management in Nursing Practice the first written format of the official nursing curriculum for the International Association for the Study of Pain (IASP) co-published by SAGE and IASP.

Undergraduate and newly qualified nurses need to develop their professional nursing knowledge and skills for competency in pain management in nursing practice which is a truly vital area of patient care in primary, secondary and tertiary settings.

Pain-related research-based knowledge, investigative technologies and range and types of pain treatments and interventions are advancing rapidly. Multidisciplinary team service delivery of pain prevention and management is a key aspect of population health. Nurses have a major influence on patients and their families and their health outcomes through patient education and support, promoting monitoring of and adherence to treatment regimens and modification of lifestyles.

In providing a readable and up-to-date synthesis of pain theories and models and their application to modern day, individualised, patient-centred pain management in nursing practice, this book will be an invaluable contribution to the continuing pain management education of undergraduate and newly qualified nurses in Ireland and internationally.

Finally I wish to acknowledge and recognise the valuable contribution Dr Wright has made to the development of a strong evidence base to guide safe practice.

Acknowledgements

[Page xii]

This book, first suggested in early 2011, is the product of a collaboration between the Editor in Chief of the International Association for the Study of Pain, Professor Maria Adele Giamberardino, and her team and the Senior Commissioning and Associate Editors of SAGE, London, Alex Clabburn and Emma Milman, and their team. I owe each a debt of gratitude for their expert guidance during the lengthy process of project development for this book.

I am exceptionally privileged to have been granted permission to write this book, the fruition of an idea based on my academic years of experience teaching pain management (based on the curriculum of the International Association for the Study of Pain (IASP)) to undergraduate nurses in several universities in Ireland. This book aims to provide undergraduate nursing students with easy access to the IASP nursing curriculum content and basic concepts and theories of pain required for entry-level qualified nurses. I hope this book will facilitate the continued promotion of quality patient care in pain management in nursing practice worldwide.

I am indebted to President Professor Brian MacCraith, colleagues in Senior Management, Dr Gerry Moore, Head of Department of the School of Nursing and Human Sciences, Dublin City University (DCU) and DCU Information Systems and Services for their kind support throughout the writing of this book. I am also indebted to DCU Nursing Librarian Amanda Halpin for her guidance in establishing excellent book and online library resources in pain management. This book was also made possible through the kind assistance of librarians in Trinity College Dublin.

My sincere gratitude is extended to President Professor Laserina O'Connor, officers and colleagues on the committee of the Irish Pain Society, Chapter of the International Association for the Study of Pain, for their truly invaluable support and encouragement during the writing of this book.

I would like to thank my family and my extensive support network for their kindness to me during the writing of this book. A special thank you to my current and former mentors globally who continue to inspire and encourage me. Latest research developments provide more hope for prevention, innovative treatments and educational interventions to improve quality of life for patients with pain – people working together to reduce pain and its associated evil.

Publisher's Acknowledgements

[Page xiii]

Every effort has been made to contact the copyright holders of third-party materials in the text. However, if any copyright owners have not been contacted, the publishers will be pleased to make the necessary arrangements at the first opportunity.

Figure 3.3: The Gate Control Theory is from Adams, N. (1997) The Psychophysiology of Low Back Pain. Churchill Livingstone, p.48. Republished with permission of Elsevier.

Figure 3.4: Top-down factors in pain is from Fields, H.L. (1992) Is there a facilitating component to central pain modulation? American Pain Society Journal, 1: 139–141, Figure 1. Republished with permission of Elsevier.

Figure 4.1: The psychobiological model of chronic pain is from Flor, H. and Turk, D.C. (2011) Chronic Pain: An Integrated Biobehavioural Approach. Seattle, WA: International Association of the Study of Pain (IASP). Copyright (2011). The figure has been reproduced with permission of the International Association for the Study of Pain® (IASP). The figure may NOT be reproduced for any other purpose without permission.

Figure 4.2: Mechanisms of normal sensitization and central sensitization is from Woolf, C.J. (2011) Central sensitization: implications for the diagnosis and treatment of pain. Pain, 152: S2-S15. Copyright (2011). The figure has been reproduced with permission of the International Association for the Study of Pain® (IASP). The figure may NOT be reproduced for any other purpose without permission.

Figure 6.1: The common and distinct components of the patient centred approach and biopsychosocial model is from Creed, F. (2005) Are the patient-centered and biopsychosocial approaches compatible? In P. White (ed.) Biopsychosocial Medicine: An Integrated Approach to Understanding Illness. Oxfrod: Oxford University Press. Copyright (2005). Republished with permission of Oxford University Press.

Table 6.3: Facilitative and blocking behaviours used by nurses when communicating with patients with cancer is from Wilkinson, S. (1991) Factors which influence how nurses communicate with cancer patients. Journal of Advanced Nursing, 16, 677–688. Copyright (1991). Republished with permission of John Wiley and Sons.

Figure 7.1: Analgesia system of the brain and spinal cord. Copyright (2011). This figure was published in Hall, J.E. (2011) Guyton and Hall Textbook of Medical Physiology (12th edn). Copyright Elsevier. Republished with permission.

Figure 9.1: A model regarding brain circuitry involved in the transition of acute to chronic pain is from Apkarian, A.V., Hashmi, J.A., Baliki, M.N. (2011) Pain and the [Page xvi]brain: specificity and plasticity of the brain in clinical chronic pain. Pain, 152: S49–S64. Copyright (2011). The figure has been reproduced with permission of the International Association for the Study of Pain® (IASP). The figure may NOT be reproduced for any other purpose without permission.

The extract from The Declaration of Montréal is reprinted with permission of the International Association for the Study of Pain® (IASP). The Declaration may NOT be reproduced for any other purpose without permission.

The extract from the Desirable Characteristics of National Pain Strategies: Recommendations in Chapter 14 is reproduced with permission of the International Association for the Study of Pain® (IASP). The extract may NOT be reproduced for any other purpose without permission.

The extract from the SIP Road Map in Chapter 14 is from Societal Impact of Pain (SIP) Societal Impact of Pain. Available at: www.sipplatfonn.eu/home.html. Republished with permission of Grünenthal Europe and Australia.

The extract from Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (Institute of Medicine, USA) in Chapter 14 is republished with permission from the National Academies Press.

The extract from the World Medical Association resolution in Chapter 14 is republished with permission of the World Medical Association. Copyright, World Medical Association. All Rights Reserved.

Glossary

unpleasant sensory and emotional experience associated with tissue damage and with activation of nociceptor transducers at the site of local tissue damage.

Addiction

a behavioural pattern of craving for and compulsive use of a substance despite harm.

Afferent neurons

neurons (nerve fibres) which conduct nerve impulses from the body periphery to the central nervous system via the spinal cord.

Agonist

a chemical (drug) substance capable of combining with a cell receptor and initiating the same action or response typically produced by the binding of an endogenous substance.

Allodynia

pain due to a stimulus which does not normally provoke pain.

Analgesia

absence of pain in response to stimulation which would normally be painful.

Antagonist

a chemical that opposes the action of a drug or an endogenous substance by combining with and blocking its receptor.

Assessment

the act of making a judgment; in pain management a clinical judgement about the nature of the range of pain characteristics and their impact on the patient's health and well being.

Autonomy

quality or state of being self-governing.

Aversive stimulus

stimulus which causes avoidance behaviour because of its noxious or punishing nature; chronic pain is an aversive stimulus which may result in reduced physical activity in order to avoid the associated pain.

Avoidance behaviour

response to avoid an (anticipated) aversive stimulus.

Bereavement

the death of a family or close friend; the state of being bereaved (deprived) of someone close.

Biopsychosocial

regarding a person's personal context, comprised of any computation of biological, genetic, racial, sex and age (bio), emotional, cognitive and spiritual (psycho) and cultural, environmental and ethnic (social) factors.

Cancer pain

a compilation of acute and chronic pain associated with any aspects of the person's experience of cancer including disease progression and associated treatments [Page 283](e.g. consequences of chemotherapy, radiotherapy and/or surgery) the term ‘cancer pain’ does not distinguish between acute and chronic pain in the context of cancer.

Cardiac syncope

a temporary reduction of blood flow to the brain causing faintness due to abnormalities of the heart such as abnormal heartbeat, valve or muscle structure or function.

Care

responsibility for or attention to health, well-being and safety of another person or persons.

Catastrophising

magnification of pain-related stimuli accompanied by negative outlook and sense of loss of control.

Central neuropathic pain

pain caused by a lesion or disease of the central somatosensory nervous system.

Central sensitisation

increased responsiveness of nociceptive neurons in the central nervous system to normal or subthreshold afferent input.

Chronic pain

unpleasant sensory and emotional experience which may be elicited by injury or disease, usually perpetuated by factors that are removed from the original cause of pain and extending beyond the expected period of healing.

Compassion

sympathetic awareness of another's distress with a desire to alleviate it.

Competency

having the required qualities of abilities and skills.

Component

a constituent part.

Congruence

quality or state of agreeing; in communication, accepting the person's perspective.

Context

interrelated conditions in which something exists or occurs.

Culture

beliefs, customs, behaviours and attitudes of a particular society or group.

Curative

a course of treatment (for example, pharmacological, surgical or other type of appropriate therapy) which results in remission of signs and/or symptoms of a disease especially during a prolonged period of observation.

Delirium

a cognitive disorder characterised by a confusional state with varying psychomotor agitation, illusions and hallucinations.

Dermatomes

segmental fields of sensation on the skin, each innervated by a spinal nerve.

Determinant

a thing that controls or influences future events in a given context, e.g. socio-economic determinants of health.

Diagnosis

The identification of a disease by examination of the patient, their signs and symptoms and relevant tests.

[Page 284]Disability

inability to function socially or pursue an occupation because of physical or mental impairment causing loss of capacity; refers to optimal functionality obtained after full rehabilitation.

Disease

a condition which impairs normal functioning and is typically manifested by distinguishing signs and symptoms.

Distress (NCCN definition)

a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis; the term equally applies to people with pain and is chosen to avoid stigmatization.

Dynorphins

one of three kinds of endogenous opioids.

Efferent neurons

neurons which conduct nerve impulses from the central nervous system towards internal organs, tissues or the body periphery.

Empathy

the ability to be sensitive to (putting oneself in another's shoes) and to try to understand the thoughts and feelings of another person, while recognising separateness from the other and acknowledging the uniqueness of their experience (without losing the ‘as if’ quality).

Empower

to give power to a person or people; in the healthcare context to afford the patient/close other status to facilitate him or her to proactively engage in their own healthcare/that of a close other.

Endogenous opioids

family of peptide neurotransmitters.

Enkephalins

one of three kinds of endogenous opioids.

Endorphins

one of three kinds of endogenous opioids.

Epidemiology

the study of the incidence, prevalence and control of diseases in populations.

Ethnic

a particular kindred affiliation or group with shared traditions and customs.

Ethos

the distinguishing guiding beliefs of a person, group, or institution.

Ethics

a theory or system of moral values referring to and defining good or bad behaviour.

Etiology

the cause of a disease or abnormal condition.

Forebrain

Prosencephalon the front division of the neural tube containing the cerebral hemispheres, thalamus and hypothalamus.

[Page 285]Genetic

relating to or caused by genes.

Grief

major distress usually associated with severe loss and/or suffering.

Hind brain

Rhombencephalon the rear division of the brain containing the cerebellum pons and medulla.

Humanism

philosophy which stresses an individual's value, dignity, and capacity for self-actualization through reason.

Hyperalgesia

an increased pain response to a stimulus that is normally painful.

Hypoalgesia

a diminished pain response to a stimulus that is normally pain.

Illness

the subjective biopsychosocial experience of a disease or condition.

Incidence

the rate of occurrence of new cases of a particular disease in a given population.

Integrated care

patient care which is coordinated among and between different disciplines; represents the ideal of interdisciplinary care and may be based on formulated care pathways.

Interdisciplinary team (see also multidisciplinary team)

the dynamic interaction of the multidisciplinary team implying optimal communication and cooperation between and among the healthcare professional team members, including the patient.

Measurement: in pain

a quantified subjective pain experience.

Mesmerism

a type of induced hypnotic trance based on the principle of Animal Magnetism promulgated by Anton Mesmer in the 18th century.

Metabolite

drug constituent following metabolism. For example, the liver metabolizes about two-thirds of a dose of oral morphine to inactive M3G metabolites and one-third to active M6G metabolites.

Metastases

spread of a primary cancer tumour to another site in the body by the spread of cancer cells through the body's circulatory systems.

Midbrain

Mesencephalon the area of the brain situated below the hypothalamus and above the pons.

Modulation

a reversible change in histological structure due to physiological factors.

Mourning

a time of sadness following a bereavement when grief is experienced.

Multidisciplinary team

concept first formulated by Professor John Bonica, anaesthetist and founder of the Internal Association for the Study of Pain, to have a team of healthcare professionals with different professional skills and competencies to facilitate the patient's optimal functional recovery in all spheres of quality of life.

pain caused by a lesion or disease of the somatosensory nervous system.

Neuropathy

a disturbance of function or pathological change in a nerve.

Neuroplasticity

nociceptive input to the nervous system as changed responses to stimuli, leading to structural and functional neuronal change.

Neurovegetative

particularly relevant to chronic, especially visceral pain, related to the autonomic nervous system and limbic system; the patient may show signs of emotional distress, nausea, vomiting, anxiety and changes in vital signs.

Nocebo effects

the adverse treatment effects induced by a dummy medicine or intervention which contains no detrimental or toxic substance.

Nociception

the neural process of encoding noxious stimuli.

Nociceptive neuron

a central or peripheral neuron of the somatosensory nervous system that is capable of encoding noxious stimuli.

Nociceptive pain

pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.

Nociceptive stimulus

an actual or potentially damaging event transduced and encoded by nociceptors.

Nociceptor

a high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli.

Noxious stimulus

a stimulus that is damaging or threatens damage to normal tissues.

Pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Pain behaviour

observable verbal and non-verbal actions which indicate that a person may be experiencing pain and suffering.

Pain threshold

the minimum intensity of a stimulus that is perceived as painful.

Pain tolerance level

the maximum intensity of a pain-producing stimulus a person is willing to tolerate.

Palliative

treatments and management interventions which aim to control the signs and symptoms of a malignant (especially metastatic cancer) or non-malignant (for example, multiple sclerosis) incurable disease to improve the patient's quality of life; (from Latin palliare: to cloak).

Perception

awareness of elements of the environment through the five senses; also implies additional cognitive awareness through organisation and interpretation of information.

[Page 287]Peripheral sensitization

increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields.

Person-centered medicine

practice of holistic care in which the patient is a person at the centre of their care.

Placebo

a dummy medicine, surgical procedure or therapeutic intervention, which, in the context of a clinical trial (the only situation in which giving a dummy intervention for pain is ethical) the patient believes could be the real thing; frequently used to control patients’ expectations about the efficacy of an intervention.

Placebo effect

the positive benefits experienced by the recipient of the placebo intervention, which are generally only achieved with an active treatment intervention.

Prognosis

predication about the likelihood of duration of and recovery from a disease/illness.

Prevalence

percentage of a specific population with a particular disease at a given time.

Race

a person's unchangeable genetic and biological characteristics such as eye and skin colour.

Rehabilitation

restoration of maximum physiological and psychosocial functioning from a state of impairment.

Reliability

in pain measurement: the extent to which a measuring tool yields the same results on repeated trials.

Sign

objective evidence of disease.

Stimulus

an event that prompts a change or a reaction.

Substrate

a substance acted upon; base, underlayer.

Suffering

subjective perceived threat to the integrity of the person (in response to unrelieved pain) associated with feelings of helplessness, hopelessness and lack of controllability.

Symptom

subjective evidence of disease or physical disturbance.

Synapse

the junction point from one neuron to the next and the point of information transmission.

Systems theory

theory with broad applicability to all types of sciences; in the context of health care: complex, adaptable and self-regulating relationships between the person and his or her environment; recognising health services as potentially adaptive systems with many interacting elements and computations, with the service user as the actively participating patient experiencing illness influenced by social, psychological and cultural factors.

[Page 288]Transduction

action or process of converting something (especially energy) into another form.

Utility

the quality or extent of usefulness.

Validity

relevant and meaningful; in pain measurement: that a scale measures what it purports to measure.

Variable

characterised by changes or variations; in pain measurement, measurable characteristics of pain which may vary such as intensity, temporality, location and quality.

Appendix

[Page 289]

The following table is a general guide only for non-opioid and weak opioid medications for Steps 1 and 2 of the WHO Analgesic Ladder. Please check the relevant, up-to-date National Formulary for all drug dosages, routes and schedules of administration, adverse effects (many of which are not listed on this table) and contraindications, especially in pregnancy, pre-term infants and lactating mothers, for which many drugs are contraindicated. Drugs can usually be given through a number of different routes, in varying formats and dosages, which must be prechecked. Time to analgesic onset is highly variable and half-life is often the dose and route taken. Many drugs interact with alcohol and may also impair driving ability.

[Page 295]Commonly used adjuvant medications for Steps 1, 2 and 3 of the WHO Analgesic Ladder; all doses (based on BNF Formularies) are approximate only, and need to be adjusted according to patient response. Please check the relevant up-to-date National Formulary for all drug dosages, routes and schedules of administration, adverse effects (many of which are not listed on this table), contraindications especially in pregnancy, pre-term infants and lactating mothers, for which many drugs are contra-indicated. Drugs can usually be given through a number of different routes, in varying formats and dosages which must be prechecked; time to analgesic onset is highly variable and half-life is often dependent on dose and route. Many drugs interact with alcohol and may also impair driving ability.

All doses (based on BNF Formularies) are approximate only, and need to be adjusted according to patient response! (NR = not recommended)

Please check the relevant up-to-date National Formulary for all drug dosages, routes and schedules of administration, adverse effects (many of which are not listed on this table), contraindications especially in pregnancy, pre-term infants and lactating mothers, for which many drugs are contra-indicated. Drugs can usually be given through a number of different routes, in varying formats and dosages which must be prechecked; time to analgesic onset is highly variable and half-life is often dose and route. Many drugs interact with alcohol and may also impair driving ability. NB all opioids can induce potentially fatal respiratory depression at therapeutic doses: Naloxone must be available to counter respiratory depression/coma.